Bill Text: VA SB98 | 2024 | Regular Session | Prefiled
Bill Title: Health insurance; if prior authorization request is approved for prescription drugs.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Passed) 2024-04-02 - Governor: Acts of Assembly Chapter text (CHAP0338) [SB98 Detail]
Download: Virginia-2024-SB98-Prefiled.html
Be it enacted by the General Assembly of Virginia:
1. That §38.2-3407.15:2 of the Code of Virginia is amended and reenacted as follows:
§38.2-3407.15:2. Carrier contracts; required provisions regarding prior authorization.
A. As used in this section, unless the context requires a different meaning:
"Carrier" has the same meaning ascribed thereto in subsection A of §38.2-3407.15.
"Prior authorization" means the approval process used by a carrier before certain drug benefits may be provided.
"Provider contract" has the same meaning ascribed thereto in subsection A of §38.2-3407.15.
"Supplementation" means a request communicated by the carrier to the prescriber or his designee, for additional information, limited to items specifically requested on the applicable prior authorization request, necessary to approve or deny a prior authorization request.
B. Any provider contract between a carrier and a participating health care provider with prescriptive authority, or its contracting agent, shall contain specific provisions that:
1. Require the carrier to, in a method of its choosing, accept telephonic, facsimile, or electronic submission of prior authorization requests that are delivered from e-prescribing systems, electronic health record systems, and health information exchange platforms that utilize the National Council for Prescription Drug Programs' SCRIPT standards;
2. Require that the carrier communicate to the prescriber or his designee within 24 hours, including weekend hours, of submission of an urgent prior authorization request to the carrier, if submitted telephonically or in an alternate method directed by the carrier, that the request is approved, denied, or requires supplementation;
3. Require that the carrier communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within two business days of submission of a fully completed prior authorization request, that the request is approved, denied, or requires supplementation;
4. Require that the carrier communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within two business days of submission of a properly completed supplementation from the prescriber or his designee, that the request is approved or denied;
5. Prohibit the carrier from revoking, limiting, conditioning, modifying, or restricting a prior authorization if such prior authorization request has been approved and services, drugs, or supplies have been provided or delivered to the patient consistent with such prior authorization unless there is evidence that the request was approved based on fraud or misinformation. Nothing in this subdivision shall require a carrier to renew a prior authorization that has expired or is about to expire. For the purposes of this subdivision, "prior authorization" means the approval process used by a carrier before certain drug benefits or procedures may be provided.
6. Require that if the prior authorization request is denied, the carrier shall communicate electronically, telephonically, or by facsimile to the prescriber or his designee, within the timeframes established by subdivision 3 or 4, as applicable, the reasons for the denial;
6. 7. Require
that prior authorization approved by another carrier be honored, upon the
carrier's receipt from the prescriber or his designee of a record demonstrating
the previous carrier's prior authorization approval or any written or
electronic evidence of the previous carrier's coverage of such drug, at least
for the initial 30 90 days of a member's
prescription drug benefit coverage under a new health plan, subject to the
provisions of the new carrier's evidence of coverage;
7. 8. Require
that a tracking system be used by the carrier for all prior authorization requests
and that the identification information be provided electronically,
telephonically, or by facsimile to the prescriber or his designee, upon the
carrier's response to the prior authorization request;
8. 9. Require that the carrier's
prescription drug formularies, all drug benefits subject to prior authorization
by the carrier, all of the carrier's prior authorization procedures, and all
prior authorization request forms accepted by the carrier be made available
through one central location on the carrier's website and that such information
be updated by the carrier within seven days of approved changes;
9. 10. Require a carrier to honor
a prior authorization issued by the carrier for a drug, other than an opioid, regardless
of changes in dosages of such drug, provided such drug is prescribed consistent
with U.S. Food and Drug Administration-labeled dosages;
10. 11. Require a
carrier to honor a prior authorization issued by the carrier for a drug
regardless of whether the covered person changes plans with the same carrier
and the drug is a covered benefit with the current health plan;
11. 12. Require a
carrier, when requiring a prescriber to provide supplemental information that
is in the covered individual's health record or electronic health record, to
identify the specific information required;
12. 13. Require
that no prior authorization be required for at least one drug prescribed for
substance abuse medication-assisted treatment, provided that (i) the drug is a
covered benefit, (ii) the prescription does not exceed the FDA-labeled dosages,
and (iii) the drug is prescribed consistent with the regulations of the Board
of Medicine;
13. 14. Require
that when any carrier has previously approved prior authorization for any drug
prescribed for the treatment of a mental disorder listed in the most recent
edition of the Diagnostic and Statistical Manual of Mental Disorders published
by the American Psychiatric Association, no additional prior authorization
shall be required by the carrier, provided that (i) the drug is a covered
benefit; (ii) the prescription does not exceed the FDA-labeled dosages; (iii)
the prescription has been continuously issued for no fewer than three months;
and (iv) the prescriber performs an annual review of the patient to evaluate
the drug's continued efficacy, changes in the patient's health status, and
potential contraindications. Nothing in this subdivision shall prohibit a
carrier from requiring prior authorization for any drug that is not listed on
its prescription drug formulary at the time the initial prescription for the
drug is issued;
14. 15. Require a
carrier to honor a prior authorization issued by the carrier for a drug
regardless of whether the drug is removed from the carrier's prescription drug
formulary after the initial prescription for that drug is issued, provided that
the drug and prescription are consistent with the applicable provisions of
subdivision 13;
15. 16. Require a carrier,
beginning July 1, 2025, notwithstanding the provisions of subdivision 1 or any
other provision of this section, to establish and maintain an online process
that (i) links directly to all e-prescribing systems and electronic health
record systems that utilize the National Council for Prescription Drug Programs
SCRIPT standard and the National Council for Prescription Drug Programs Real
Time Benefit Standard; (ii) can accept electronic prior authorization requests
from a provider; (iii) can approve electronic prior authorization requests (a)
for which no additional information is needed by the carrier to process the
prior authorization request, (b) for which no clinical review is required, and
(c) that meet the carrier's criteria for approval; and (iv) links directly to
real-time patient out-of-pocket costs for the office visit, considering
copayment and deductible, and (v) otherwise meets the requirements of this
section. No carrier shall (a) impose a fee or charge on any person for
accessing the online process as required by this subdivision or (b) access,
absent provider consent, provider data via the online process other than for
the enrollee. No later than July 1, 2024, a carrier shall provide contact
information of any third-party vendor or other entity the carrier will use to
meet the requirements of this subdivision or the requirements of §
38.2-3407.15:7 to any provider that requests such information. A carrier that
posts such contact information on its website shall be considered to have met this
requirement; and
16. 17. Require a
participating health care provider, beginning July 1, 2025, to ensure that any
e-prescribing system or electronic health record system owned by or contracted
for the provider to maintain an enrollee's health record has the ability to
access, at the point of prescribing, the electronic prior authorization process
established by a carrier as required by subdivision 15 and the real-time
patient-specific benefit information, including out-of-pocket costs and more
affordable medication alternatives made available by a carrier pursuant to §
38.2-3407.15:7. A provider may request a waiver of compliance under this
subdivision for undue hardship for a period specified by the appropriate
regulatory authority with the Health and Human Resources Secretariat.
C. The Commission shall have no jurisdiction to adjudicate individual controversies arising out of this section.
D. This section shall apply with respect to any contract between a carrier and a participating health care provider, or its contracting agent, that is entered into, amended, extended, or renewed on or after January 1, 2016.
E. Notwithstanding any law to the contrary, the provisions of this section shall not apply to:
1. Coverages issued pursuant to Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq. (Medicare), Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq. (Medicaid), Title XXI of the Social Security Act, 42 U.S.C. §1397aa et seq. (CHIP), 5 U.S.C. §8901 et seq. (federal employees), or 10 U.S.C. §1071 et seq. (TRICARE);
2. Accident only, credit or disability insurance, long-term care insurance, TRICARE supplement, Medicare supplement, or workers' compensation coverages;
3. Any dental services plan or optometric services plan as defined in §38.2-4501; or
4. Any health maintenance organization that (i) contracts with one multispecialty group of physicians who are employed by and are shareholders of the multispecialty group, which multispecialty group of physicians may also contract with health care providers in the community; (ii) provides and arranges for the provision of physician services by such multispecialty group physicians or by such contracted health care providers in the community; and (iii) receives and processes at least 85 percent of prescription drug prior authorization requests in a manner that is interoperable with e-prescribing systems, electronic health records, and health information exchange platforms.